Cost-utility analysis of early reconstruction surgery versus conservative treatment for anterior cruciate ligament injury in a lower-middle income country.

BACKGROUND: The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia. METHODS: A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 - three times the Indonesian GDP per capita in 2021 - the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE). RESULTS: The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%. CONCLUSIONS: Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.

The mini-open procedure with a modified figure of eight for managing sacrococcygeal fracture-dislocation: A case report and literature review.

INTRODUCTION AND IMPORTANCE: A fracture associated with an anteriorly displaced fragment may induce soft tissue disintegration. However, this might be avoided by maintaining the stability of the sacrococcygeal bone. Fixation by using less invasive modalities is needed to improve the outcome. CASE PRESENTATION: A 37-year-old female came with tailbone pain, which lasted around one month. There was a history of falling in a sitting position a month before hospital admission. Tenderness was positive while palpating the perineal site. A radiography examination shows a fracture in the sacrococcygeal segment with anterior dislocation. The patient was diagnosed with a sacrococcygeal fracture and anterior dislocation. CLINICAL DISCUSSION: We performed a mini-open procedure using a modified figure-of-eight technique to reconnect the sacrococcygeal bone. Suturing was performed through the skin in the painful area, and then the bone at the injured site was reduced. As an outcome, there was an improvement in the Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and EuroQol-5 Dimensions (EQ5D) scores. CONCLUSION: A mini-open procedure with a modified figure of eight is a simple and valuable method for correcting the sacrococcygeal components.

Pulsed radiofrequency of iPACK (interspace between the popliteal artery and the posterior knee capsule) for pain control following meniscus repair - A case report.

Adequate postoperative pain control is an essential factor for the success of rehabilitation programs after meniscus repair (MR). The pulsed radiofrequency of the interspace between the popliteal artery and the posterior knee capsule (PRF-iPACK) is a recently developed method. This study aimed to evaluate the use of PRF-iPACK in patients who underwent MR. We performed PRF-iPACK guided by ultrasonography for patients who underwent MR with aggravated pain. PRF-iPACK was performed following MR four weeks after surgery. The pain was evaluated using the visual analogue scale (VAS), Lysholm score, and the Euroqol-5 Dimension (EQ-5D). In this study, two patients participated. For the results, a week and three months after treatment, the mean VAS score, Lysholm score, and EQ5D improved from 7 to 1 and 0 respectively, and 42 to 86 and 90 respectively, and 0.48 to 0.82 and 0.92 respectively. We concluded that PRF-iPACK is an adequate and safe procedure for managing postoperative pain after MR. It may enhance the postoperative rehabilitation program.

Ligament reconstruction with modified suture anchor fixation technique for chronic distal radioulnar joint instability: A case report and literature review.

INTRODUCTION: The chronic instability of the DRUJ should be appropriately treated. Ligament reconstruction in the original technique needs an adequate length of the graft, which needs to be modified in such a case. CASE PRESENTATION: A 27-year-old male presented with right wrist pain accompanied by limited movement that has been felt for the last two months. There was an obvious deformity with tenderness. Palpation revealed a positive ballottement and piano-key sign test. An X-ray examination revealed a union fracture one-third distally on the right radius bone with dorsal dislocation of the right distal radioulnar joint. The result of an MRI confirmed a triangular fibrocartilage complex tear. The patient was diagnosed with chronic DRUJ instability. DISCUSSION: We performed a chronic DRUJ reconstruction using the harvesting palmaris longus tendon. However, the length of the graft is too short. Further, we performed a modified technique with suture anchor fixation for this patient. This technique could be a helpful alternative if the length of the graft is insufficient. As a result, there was an improvement in the DASH score and EQ5D questionnaires. CONCLUSION: Chronic DRUJ instability could be treated by ligament reconstruction with modified suture anchors fixation in the inadequate length of the graft situation.

Successful megaprosthesis in a nearly amputated lower extremity after crush injury: A case report and literature review.

Crush injury is one of the most challenging decisions for a surgeon to decide whether to proceed with an amputation or salvage a limb. We presented a 24-year-old man who complained of having suffered a crushed thigh 12 h before admission to the hospital. The patient was driving a truck and hit the iron bridge barrier, which penetrated his left thigh. The patient's left foot was cold, pallid, and pulseless, with a MESS score of 11. The femur x-ray showed a displaced fracture of the left femur associated with a 15 cm bone defect. The patient was diagnosed with a crush injury on the left femur with vascular compromise. We performed a proximal femoral megaprosthesis for a crush injury on the lower extremity, After the sixth year's follow-up, it shows a good outcome and increased quality of life for this patient. In addition, there was an improvement in the Harris Hip Score and EQ5D score. Megaprosthesis used to treat a crush injury revealed good functional outcomes despite the MESS score of 11. A multi-professional approach to the patient is essential for decision-making regarding limb salvage rather than the use of a score.

Responsiveness of the Indonesian Versions of the Anterior Cruciate Ligament-Return to Sport After Injury Score, the International Knee Documentation Committee Subjective Knee Form, and the Lysholm Score in Patients With ACL Injury.

Background: The Indonesian versions of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee subjective knee form (IKDC), and the Lysholm scores are considered valid and reliable for Indonesian-speaking patients with anterior cruciate ligament (ACL) injury. Purpose/Hypothesis: The purpose of this study was to determine the responsiveness of the ACL-RSI, IKDC, and Lysholm scores in an Indonesian-speaking population with ACL injury. It was hypothesized that they would have good responsiveness. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Between March 1, 2021, and February 28, 2022, patients with an ACL injury at a single hospital in Indonesia were asked to complete the ACL-RSI, IKDC, and Lysholm scores before either reconstruction surgery or nonoperative treatment. At 6 months after treatment, the patients completed all 3 scores a second time, plus a global rating of change question. The distribution-based and the anchor-based methods were used to study responsiveness. For each scale, the standardized response mean, minimal clinically important difference (MCID), and minimal detectable change (MDC; at the group [MDCgr] and individual [MDCind] levels) for each scale were determined. Results: Of 80 eligible patients, 75 (93.8%) completed the study. The standardized response means for the ACL-RSI, IKDC, and Lysholm scores were 1.59, 1.72, and 1.51, respectively, indicating good responsiveness. The MCIDs for the ACL-RSI, IKDC, and Lysholm scores were 6.8, 7.8, and 4.8, respectively; all MCIDs were larger than that of the MDCgr (1.1, 0.7, and 0.6, respectively). At the individual level, the MCID for the IKDC was larger than the MDCind (7.8 vs 5.8). However, the MCIDs for ACL-RSI and Lysholm scores were smaller than those of the MDCind (6.8 vs 10.9 and 4.8 vs 5.1, respectively). Conclusion: The Indonesian ACL-RSI, IKDC, and Lysholm scores indicated good responsiveness and can be used in the follow-up of patients after ACL injury, especially at the group level. In individual patients, IKDC was found to be more efficient than the ACL-RSI or Lysholm scores for detecting clinically important changes over time after ACL treatment.

Translation, Validity, and Reliability of the Indonesian Version of the Anterior Cruciate Ligament-Return to Sport After Injury Scale.

Background: The Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale measures athletes' emotion, confidence, and risk appraisal when returning to sports after an anterior cruciate ligament (ACL) injury and/or ACL reconstruction (ACLR). Purpose: To translate the ACL-RSI into the Indonesian language and to assess its validity and reliability in Indonesian-speaking patients after ACLR. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: After a forward-and-backward translation procedure, the validity and reliability of the Indonesian version of the ACL-RSI (I-ACL-RSI) were investigated. Patients who had undergone ACLR at a single hospital were asked to complete 4 questionnaires: I-ACL-RSI, Injury-Psychological Readiness to Return to Sport, Tampa Scale of Kinesiophobia, and International Knee Documentation Committee. After a 2-week interval, patients were asked to complete the I-ACL-RSI a second time. Following the COSMIN reporting guidelines (Consensus-Based Standards for the Selection of Health Measurement Instruments), we determined construct validity using hypothesis testing, as well as test-retest reliability, internal consistency, floor and ceiling effects, and measurement error. Results: Of 200 eligible patients, 102 (51%) were included in the analysis. All predefined hypotheses on correlations between the I-ACL-RSI and the other questionnaires were confirmed, indicating good construct validity. An intraclass correlation coefficient of 0.90 (2-way random, type agreement) was found for the first and second I-ACL-RSI scores, indicating good test-retest reliability. A Cronbach α of 0.95 indicated good internal consistency, and no floor or ceiling effects were found. The standard error of measurement was 3.9, with the minimal detectable change calculated as 10.9 points at the individual level and 1.1 points at the group level. Conclusion: Based on the study findings, the I-ACL-RSI can be considered a valid and reliable questionnaire for Indonesian-speaking patients after ACL injury and/or ACLR.

Conservative treatment for idiopathic frozen shoulder: Is supervised neglect the answer? A systematic review.

OBJECTIVE: The aim of this study was to assess the most beneficial conservative treatment for idiopathic frozen shoulder. METHODS: A total of 498 frozen shoulder cases (mean age 52.4 + 3.8 years) from 10 articles consisting of seven level 1B and three level 2B studies were included after searching electronic databases of Pubmed, Embase, and Scopus from 1st January 2000 up to 30th October 2020. Patients were followed up for 7.9 + 7.7 and 3 (1-24) months on average. The mean duration of symptoms the patient experienced before receiving conservative treatment was 22.5 + 6.8 weeks. This study measured clinical outcomes using the improvement of active range of motion (ROM) and patient-reported outcome measures (PROMs). Numerical data analyses were calculated based on weighted means according to the number of patients involved in each study. RESULTS: When comparing the ranges of motion of active flexion, abduction, external rotation, and internal rotation it was observed that conservative treatments increased the active ROM of flexion by 57.9o (22.1%), abduction by 62.4o 116 (99.1%), external rotation by 37o (230.4%), and internal rotation by 22.1o 117 (71.2%). From all current included literature on idiopathic frozen shoulder, supervised neglect resulted in the highest percentage of ROM improvement in flexion, abduction, external rotation, and internal rotation. Patients receiving supervised neglected treatment significantly improved their patient-reported outcome measures (PROMs). CONCLUSION: Although according to the present literature supervised neglect is the most beneficial conservative therapy, physiotherapy has been proven to provide adequate range of motion and clinical outcome improvement. LEVEL OF EVIDENCE: Level II, Therapeutic Study.

Burden and Cost of Anterior Cruciate Ligament Reconstruction and Reimbursement of Its Treatment in a Developing Country: An Observational Study in Indonesia.

Objective: The number of anterior cruciate ligament reconstruction (ACLR) procedures is increasing. However, ACLR procedures are likely to be underbudgeted in a developing country like Indonesia. This study aimed to analyze costs for ACLR procedures in Indonesia's resource-limited context, determine the burden of ACLR, and suggest national prices for ACLR reimbursement. Methods: A retrospective observational study was conducted between 1 January and 31 December 2019 on the cost of ACLR from a payer perspective using inpatient billing records in four hospitals. The national burden of ACLR was calculated, and projected national prices for reimbursement were determined. Results: Of 80 ACLRs, 53 (66%) were isolated ACLRs and 27 (34%) ACLRs were combined with meniscus treatment. Mean hospital costs incurred per ACLR procedure were US$ 2853, with the dominant cost relating to orthopedic implant prices (US$ 1,387.80). The costs of ACLR with combined meniscus treatment were estimated as being 35% higher than isolated ACLR. The national burden of ACLR showed a total budget of US$ 367.4 million per 100,000 patients (0.03% of GDP) for ACLR with additional meniscus treatment and US$ 271.3 million per 100,000 patients (0.02% of GDP) for isolated ACLR. Conclusion: ACLR procedures in Indonesia are likely underbudgeted. Adjustments of reimbursement prices for ACLR are needed to facilitate adequate access of Indonesians to the procedures. This study demonstrated varying costs determined for ACLR in Indonesia, which entails that a new reimbursement system with improvement of national prices should become the core of transformation.

Translation and Psychometric Analysis of the Indonesian Versions of the Lysholm and Tegner Scores for Patients With Anterior Cruciate Ligament Injuries.

BACKGROUND: The Lysholm knee score and Tegner activity scale are frequently used patient-reported outcome measures in patients with anterior cruciate ligament (ACL) injuries because of their excellent psychometric properties. These questionnaires were originally developed in the English language. PURPOSE: To translate and cross-culturally adapt these measures into the Indonesian language and study their validity and reliability so that they can be used in the Indonesian-speaking population with ACL injuries. STUDY DESIGN: Cohort study (diagnosis/symptom prevalence); Level of evidence, 2. METHODS: After a forward-backward translation procedure and cross-cultural adaptation, validity and reliability were investigated. A total of 253 patients with an ACL injury were sent 4 questionnaires (36-Item Short Form Health Survey, Kujala anterior knee pain scale, Indonesian Lysholm knee score [I-LK], and Indonesian Tegner activity scale [I-TS]). The responses of those patients were analyzed. Following COSMIN guidelines, construct validity, test-retest reliability, internal consistency, floor and ceiling effects, and measurement errors were determined. The Bland-Altman method was used to explore absolute agreement. RESULTS: A total of 106 patients (42% response rate) were included in this study. Construct validity was considered to be good, as more than 75% of the predefined hypotheses on correlations between the I-LK, I-TS, and other measures were confirmed. Reliability proved excellent, with a high test-retest correlation for both questionnaires (intraclass correlation coefficient = 0.99). Bland-Altman analysis showed no systematic bias between testing and retesting. The internal consistency of the I-LK was good (Cronbach alpha = 0.73). For the I-LK and I-TS, floor and ceiling effects were less than 15% (floor: 0% and 4.7%, respectively; ceiling: 12.3% and 3.8%, respectively); the standard error of measurement was 1.8 and 0.9, respectively; the minimal detectable change at the individual level was 5.1 and 0.6, respectively; and the minimal detectable change at the group level was 2.4 and 0.5, respectively. CONCLUSION: Both the I-LK and I-TS appear to be good evaluation tools for Indonesian-speaking patients with an ACL injury.

Translation, Cross-Cultural Adaptation, Validity, and Reliability of the Indonesian Version of the IKDC Subjective Knee Form.

BACKGROUND: No questionnaire is currently available for use in patients with anterior cruciate ligament (ACL) injuries in an Indonesian population. The most-used questionnaire in clinical research for these patients is the International Knee Documentation Committee (IKDC) Subjective Knee Form, as its psychometric properties are considered to be excellent. PURPOSE: To translate the IKDC into Indonesian and assess its validity for use in Indonesian-speaking patients with ACL injuries. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: After a forward-and-backward translation procedure and cross-cultural adaptation, the validity and reliability of the questionnaire were investigated. The responses of ACL injury patients on 3 questionnaires, the Indonesian-IKDC (I-IKDC), 36-Item Short Form Health Survey, and Kujala Anterior Knee Pain Scale, were compared. Following consensus-based standards for the selection of health measurement instruments guidelines, construct validity, test-retest reliability, internal consistency, floor and ceiling effects, and measurement error were determined. The Bland-Altman method was used to explore absolute agreement. RESULTS: Of 253 ACL injury patients, 106 (42%) responded to the invitation. Construct validity was considered good, as all predefined hypotheses on correlations between the I-IKDC and other scores were confirmed. Reliability proved excellent, with a high test-retest correlation (intraclass correlation coefficient = 0.99). Bland-Altman analyses showed no systematic bias between test and retest. Internal consistency was good (Cronbach α = .90). There were no floor or ceiling effects. Standard error of measurement was 2.1, and the minimal detectable change was 5.8 at the individual level and 0.7 at the group level. CONCLUSION: The I-IKDC, as developed, appeared to be a good evaluation instrument for Indonesian patients with ACL injuries.

Isolated lateral extra-articular tenodesis enhance better rotatory knee joint stability post-primary ACL repair: Four cases report and literature review.

INTRODUCTION AND IMPORTANCE: Residual rotatory instability has been reported to occur after primary anterior cruciate ligament reconstruction. The anterolateral ligament complex of the knee has gained attention for its role in rotational instability of the knee, especially in association with anterior cruciate ligament injuries. The role of an isolated lateral extra-articular tenodesis procedure among those patients presenting with residual rotatory instability after primary anterior cruciate ligament reconstruction has not been reported on. CASE PRESENTATION: Four patients (Tegner level 4) presenting with residual rotatory instability after primary anterior cruciate ligament reconstruction without signs of graft failure, underwent an isolated lateral extra-articular tenodesis with modified Lemaire procedure. Pre- and postoperative outcome scores were assessed. At one-year follow-up, all patients reported functional knee stability. Pivot shift tests were negative and postoperative Lysholm scores were increased with a mean of 19.75 points. Tegner scores equaled the preinjury level. CLINICAL DISCUSSION: This case report showed that our four patients where successfully treated with an isolated secondary modified Lemaire procedure for residual anterolateral rotatory instability after primary anterior cruciate ligament reconstruction. CONCLUSION: An isolated secondary lateral extra-articular tenodesis procedure can be a valuable treatment option for moderate active patients with residual rotatory instability after a primary anterior cruciate ligament reconstruction without signs of graft failure.

Mini open triple tunnel- double flip button techniques in treatment of acute acromioclavicular joint injuries: Case report.

Acute acromioclavicular (AC) joint injuries are common and often occur in a contact sport activity. Most acute AC joint injuries surgery techniques focus on coracoclavicular (CC) ligament complex fixation; by single or double clavicle tunnel, but persisting vertical instability. In this paper, we introduce mini open triple tunnel- double flip button (TTDB) technique for acute AC joint dislocation by adding tunnel on clavicle to expand coverage of footprint of conoid and trapezoid ligament in order to improve vertical stability of the AC joint. This method is based on CC ligament augmentation with a double flip button/polydioxanone (PDS), combined with V-loop pulley suture for anatomical fixation. This is a prospective case report. Two professional, male basketball players in this study with a mean age of 25 years underwent surgery in 2019. Clinical subjective outcome, VAS score, Nottingham Clavicle Score, and radiological CC distance were measured before and after the operation. There were noticeable improvement in the patients' recovery after two years since the operation. We introduce TTDB technique as one of the open techniques for acute AC joint injuries in limited-resource hospital setting.